"Please lower your mask": A hard diagnosis in COVID-19 times.

PRESENTATION

A 64‐year‐old woman presented to the emergency department (ED) with a painful left ankle after an eversion ankle sprain. The patient wore a surgical mask according to hospital policy. She was a smoker and socially isolated and reported excessive alcohol consumption. First clinical examination found splinter hemorrhage and non‐palpable purpura of petechiae of the lower limbs (Figure 1). Laboratory tests were notable for raised aspartate aminotransferase, alkaline phosphatase, gamma‐glutamyltransferase, and mean corpuscular volume without anemia, but with folate deficiency. The physician removed her surgical mask during a second examination, revealing many loose teeth (Figure 2).

FIGURE 1

Nonpalpable purpura of the lower limbs

FIGURE 2

Patient loose teeth

DIAGNOSIS

A diagnosis of scurvy was suspected. Oral high‐dose vitamin C supplements (ie, 1 g/day for 2 weeks) were given immediately, before diagnosis confirmation by vitamin C plasma levels (< 3 μmol/L; reference range, 26.1–84.6 μmol/L). Complete biological recovery was achieved after 1 more month of 500 mg/day of vitamin C supplements.

The prevalence of vitamin C deficiency is estimated at 7.1% in the United States and is more frequent in patients with alcohol use disorders or eating disorders. Untreated scurvy leads to death, which underlines the importance of early diagnosis in the ED. The low availability for immediate vitamin C measurements makes it difficult to use in primary care, including the ED. Only complete examinations can help detect such a multifocal disorder. Patients must be asked to lower their surgical masks, in any context of presentation, not to neglect unexpected facial signs. This clinical case highlights one risk of misdiagnosis and delayed diagnosis during the COVID‐19 pandemic for many patients with COVID‐19 present in the ED.